PERSONAL LIABILITYAPPLICATION

CF-519 (Ed. 4-20) (COMPLETE REVERSE SIDE)

New Renewal of_______________ Combine with_________________ Issue Separate Policy (Surcharge Applies)TERM: From: __________________________ To:____________________________

APPLICANT AND MAIL ADDRESS AGENCY AND MAIL ADDRESS AGT. NO._______

Phone No.: Social Security No.: Phone No.: Fax No.:

DIRECT BILL INSTRUCTIONS: Insured Other____________________________________________________________________New Business - 1 months premium required with application.

The principal residence premises are located at (Street Address, Lot and Block No., or Sec-Twp-Range, Include 911 Address & County):______________________________________________________________________________________________________________________Occupation of the Applicant is: _____________________________________________________________________________________________

Cov/Applies Yes/No

BASE COVERAGES LIMITS OF LIABILITY PREMIUM Personal Liability $ _________________________ each occurrence .............................................. $ ______________ Medical Payments to Others $ _________________________ each person ..................................................... $ ______________ Damage to Property of Others $ _________________________ each occurrence .............................................. $ ______________

ADDITIONAL COVERAGES Additional Residence Premises Maintained (Secondary or Seasonal)

Location ___________________________________________________________________________________ $ ______________ Employer's Liability - Domestic Employees In excess of 2 - per each How many?______________ ....................... $ ______________ IncidentalOffice-Describe _______________________________________________________________________ $ ______________

OPTIONAL COVERAGES Additional Insured - Non Relative Interest __________________________________________________________ $ ______________

Name and Address of Person or Organization: _____________________________________________________ __________________________________________________________________________________________ $ ______________

Babysitting - 1-5 Children (1 Charge) No. of Children__________________ .................................................................. $ ______________NOTE: Minnesota minimum insurance requirements for this coverage are $250,000 per occurrence, subject to $100,000 per person.

BusinessActivities:WhoandWhat__________________________________________ Classification ___________ $ ______________ Inboard and Inboard/Outboard Motor Boats

Length__________Description________________________________Rated Speed (MPH)__________H.P. ____ $ ______________Length__________Description________________________________Rated Speed (MPH)__________H.P. ____ $ ______________

Outboard Motor Boats (50 H.P. and under - No Charge)Over 50 H.P.: H.P.__________Make______________________Serial No. ______________________________ $ ______________Over 50 H.P.: H.P.__________Make______________________Serial No. ______________________________ $ ______________NOTE: For rating purposes, combine the H.P. of all outboard motors used together with any single watercraft owned by the insured.

Personal Injury (Does not include Medical Payments) ..................................................................................................... $ ______________ Personal Watercraft (Per Unit) How many? _______ Description: _______________________________________ $ ______________ Recreational Vehicles (Does not cover any 2 wheel vehicles) Snowmobiles & All Terrain Vehicles (1 Charge)# _____ $ ______________

List Snowmobile(s) CC's_________________________________ List ATV(s) CC's ______________________ Residence Premises Rented to Others

No. of Families_____ - Location _________________________________________________________________ $ ______________No. of Families_____ - Location _________________________________________________________________ $ ______________

Other ________________________________________________________________________________________ $ ______________  Separate Personal Liability Policy Surcharge ................................................................................................................... $ ______________

FOR COVERAGES OR RATING SITUATIONS NOT SHOWN, REFER TO HOME OFFICE TOTAL PREMIUM $ ______________

1,000 Incl.

x

x

Box 48 Cottonwood, Minnesota 56229

UNDERWRITING REPORT (Application Returned If Not Completed)1. Date of last on-site inspection:________________________ By whom? _____________________________________________________2. Principal residence premises is: 1 Family 2 Family3. General housekeeping and condition of premises: Excellent Good Average Fair Poor4. PREVIOUS CARRIER: ______________________________________________ Was policy cancelled or non-renewed? Yes No

If yes, explain below under COMMENTS.5. How long has agent know applicant? ___________________________ Does agent recommend issurance of this policy? Yes No6. Do we have other insurance? Yes No If yes, give Policy Number: ____________________________________________________7. Are premises used for any business or professional purposes? Yes No If yes, describe below under COMMENTS.8. Does applicant own dog(s)? Yes No What breed(s)? _______________________________________________________

Has the dog(s) ever bitten anyone? Yes No If yes, explain below under COMMENTS.9. Trampolines? Yes No Swimming Pool? Yes No Above Ground? or Below Ground?

Diving Board/Slide? Yes No Fence around Pool? Yes No (Provide Picture of Pool)10. Any horses or other unusual hazards on the premises? Yes No If yes, explain under COMMENTS.11. LOSS EXPERIENCE: NONE APPLICANTS SIGNATURE

Date Cause of Loss and Property Involved Amount of LossList all losses ________________________________________________________________________________________________within the past ________________________________________________________________________________________________3 years. ________________________________________________________________________________________________

________________________________________________________________________________________________The following must be completed for all Recreational Vehicle/Watercraft Coverage

1. What is the rated speed in miles per hour? ________________________________________________________________________________2. Is the vehicle ever entered in any racing events? Yes No If yes, explain: ______________________________________________

__________________________________________________________________________________________________________________

Complete these additional questions for watercraft coverage:

1. Is the boat ever taken out of state? Yes No If yes, how often? ______________________________________________________ __________________________________________________________________________________________________________________

2. Is the boat ever used on the Great Lakes? Yes No If yes, how often? ________________________________________________ __________________________________________________________________________________________________________________

3. Istheboateverusedinanytypeoffishingcontests? Yes No If yes, how often? ________________________________________ __________________________________________________________________________________________________________________

Complete for M.V.R. information:

Name of All Operators Relationship Date of Birth Drivers License Number % Use

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

COMMENTS:

NOTICE - READ BEFORE SIGNING - As the applicant for this insurance, I grant permission to the agency listed on the front and to the underwriting department of North Star Mutual to obtain claims information from previous insurer(s) and/or reports from investigative consumer organizations as to my credit (or credit-based insurance score), character, and/or condition of the property represented on this application. I understand that I have the right to make a request in writing as to the nature of any such information that may be developed and that I have the right to request that any such information be corrected by providing documented support for such correction. If my request is denied, I understand that I have the right to appeal to the Commissioner/Director (Minnesota Commissioner of Commerce, 85 7th Place East, Suite 500, St. Paul, MN 55101-2198; Nebraska Director of Insurance, Terminal Building, 941 "O" Street, Suite 220, Lincoln, NE 68508-2089; North Dakota Commissioner of Insurance, 600 East Boulevard Avenue-5th Floor, Bismarck, ND 58505-0320; South Dakota Director of Insurance, 124 South Euclid Avenue, 2nd Floor, Pierre, SD 57501; Iowa Insurance Commissioner, Two Ruan Center, 601 Locust St. 4th Floor, Des Moines, IA 50309-3738; Wisconsin Commissioner of Insurance, PO Box 7873, Madison, WI 53707-7873). I understand that in Minnesota only, this is a temporary authorization that will expire as soon as one of the following occurs: (a) The above named company makes the underwriting decision(s) in question, or (b) one year elapses after the date I sign this authorization. However, if a policy is issued, then I authorize the above permission for subsequent amendments and renewals as long as the policy remains in-force. I understand that in Iowa only, Iowa law requires that we inform you that we will consider your claims history in determining whether to decline, cancel, nonrenew or surcharge the policy for which you are applying. In addition, any claim made by you will be reported to an insurance support organization.If this application for insurance is accepted, I grant permission to North Star Mutual to disclose information to the Mortgagee(s) or Loss Payee(s) that may be designated in this application or its(their) successor(s). (Reports prepared by insurance-support organizations may be retained by them and disclosed to others.) INSURANCE FRAUD IS A CRIME - I understand that a person who submits an application or claim information with intent to defraud an insurer is guilty of a crime.Applicant's Signature _________________________________________________________________________________________________ Date _________________________

As the Agent for the applicant, I attest that the information in this application and attachments is correct to the best of my knowledge.

Agent's Signature ____________________________________________________________________________________________________ Date _________________________